Archives: MRCP Part 2

MRCP2-1260

A 40-year-old man presents to endocrinology clinic with concerns about gynaecomastia. He had previously seen his GP for this issue, which was initially thought to be related to alcohol excess and possible liver involvement. However, after stopping alcohol and normal liver function tests, this diagnosis was ruled out. The patient has no significant medical history except for a tibial fracture a year ago and a recent diagnosis of migraines. He takes paracetamol for the migraines but finds it ineffective, especially at night. Upon further questioning, he reports difficulty maintaining an erection. On examination, he has gynaecomastia but is otherwise unremarkable. Repeat blood tests in the clinic reveal low morning serum testosterone levels, with normal FSH and LH. What additional investigation would be most helpful in making a diagnosis?

MRCP2-1261

A 55-year-old male presents with 48 hours of general malaise. 20 years ago, he underwent a resection of a pituitary mass and has since been compliant on desmopressin, levothyroxine and hydrocortisone, up until his last dose earlier in the morning. He has no other past medical history. His wife reports the patient to have had reduced oral intake for the past 2 days while he has been unwell. He has no reported head injuries, rigors or pyrexia.

On examination, his GCS is E3 V2 M5. He is cool peripherally and a temperature demonstrates 33.4 degrees under his tongue. His spot blood glucose is 2.2 mmol/l. His blood pressure is 86/50 mmhg heart rate 110/min and sinus rhythm. Blood tests demonstrate a sodium of 158 mmol/l and potassium of 4.2 mmol/l. What is your first action(s)?

MRCP2-1262

You are requested to evaluate a 50-year-old male patient who has been seen four times in the past seven days due to persistent hyperkalaemia on his blood tests. The patient has been admitted for five weeks under the care of surgeons following an AP resection of sigmoid carcinoma complicated by a superficial wound infection that required a vacuum dressing. During the previous three medical reviews, the patient had a serum potassium level greater than 6.5 mmol/l and was treated with insulin-dextrose and calcium gluconate.

The patient’s medical history includes type 2 diabetes mellitus, non-alcoholic steatohepatitis, and neuromyelitis optica diagnosed six years ago, which was stable on the last review two months ago. The patient’s regular medications include gliclazide 80mg BD, Lantus (insulin glargine) 15 units OD, prednisolone 15 mg OD, and baclofen 10 mg QDS. During this review, the patient is alert and comfortable, with a blood pressure of 135/82 mmHg, heart rate of 90/min, and sinus rhythm.

The patient’s blood tests reveal the following:

Hb 121 g/l
Platelets 334 * 109/l
WBC 8.2 * 109/l

Na+ 136 mmol/l
K+ 6.9 mmol/l
Urea 7.5 mmol/l
Creatinine 110 µmol/l
CRP 4 mg/l
Renin Raised
Aldosterone Decreased

Blood gases show the following:

pH 7.24
PaO2 (air) 15.8 kPa
PaCO2 2.2 kPa
Bicarbonate 24 mmol/l

Urinary pH = 6.2

A repeat CT abdomen and pelvis demonstrates appropriate wound healing with no local collections at the resection site. No other abdominal pathology is noted.

What is the most probable diagnosis?

MRCP2-1263

A patient with type 1 diabetes mellitus is urgently referred to the endocrinology consultant from a Dose Adjustment For Normal Eating (DAFNE) course. The nurse in the course was concerned as the patient, who is in his mid-30s, has experienced three episodes of hypoglycaemia in the past nine months, requiring assistance from his wife to increase his blood glucose levels. He follows a basal bolus regimen of long acting insulin once a night and short acting insulin three times a day, and works in a restaurant. He is an ex-smoker and drinks very little alcohol. Besides adjusting the insulin dose, what is the most appropriate course of action?

MRCP2-1264

A 24-year-old woman is brought into the emergency department by ambulance with her dad, who found her unconscious on the bathroom floor just half an hour ago. The dad had last seen her 4 hours previously and reports she was well at this time. She has a past medical history of depression and was last admitted 6 months ago with a paracetamol overdose. She has otherwise been well in herself and suffers no other medical conditions that dad is aware of. Her GCS on arrival is 8. She is found to be severely hypoglycaemic at 2.2mmol/L and is treated with IV dextrose.

As the medical registrar on call, you have been asked to assess her. She has now been on a dextrose infusion for 45 minutes with no minimal improvement. The examination is grossly normal besides a tachycardia of 110 bpm and GCS of 10/15 (M4, E3, V3). She is maintaining her own airways. Up-to-date glucose is 2.9 mmol/L, and her C-peptide and insulin are both elevated. You ask that she be given 50mL of 50% glucose IV, but she remains hypoglycaemic despite this.

What treatment options should be considered for this 24-year-old woman?

MRCP2-1265

An 80-year-old woman presents to the emergency department with complaints of confusion, dizziness, and weakness. She has experienced similar episodes in the past three months. Her medical history includes type 2 diabetes mellitus for 15 years, hypertension, and hyperlipidemia. She is currently taking metformin and glimepiride for her diabetes.

Upon examination, her vital signs are as follows: temperature 37ºC, blood pressure 120/80 mmHg, heart rate 80/min, and respiratory rate 18/min. Physical examination reveals no abnormalities.

Blood tests are ordered, and her finger-stick glucose level is found to be 2.5 mmol/L. The patient is given glucagon IM and 50 ml of 50% dextrose IV, but she remains confused. A repeat finger-stick glucose level is 2.8 mmol/L. Serum insulin and C-peptide levels, drawn before dextrose administration, are elevated.

What is the most appropriate next step in managing this patient?

MRCP2-1266

A 63-year-old woman presents for her diabetic review. She has type-2 diabetes and suffered an NSTEMI 3 months ago, resulting in a decrease in her ejection fraction. Her current medication includes metformin 500mg TDS, aspirin, statin, bisoprolol, and ramipril.

The patient’s pre-clinic blood results are as follows:

– HbA1c 59 mmol/mol (<42 mmol/mol)
– Urea 8.3 mmol/L (2.0 – 7.0)
– Creatinine 140 µmol/L (55 – 120)
– eGFR 32.8mL/min/1.73m²

Her BMI is 28.7kg/m², with a weight of 62 kg and a height of 147 cm. She recently attended a retinal screening appointment and was informed of pre-proliferative diabetic retinopathy changes. A follow-up appointment with the renal team regarding her diabetic nephropathy is scheduled for 2 weeks from now.

The patient’s main concern is experiencing hypoglycemia episodes, as she lives alone and would prefer to avoid increasing her risk of hypos if possible. What would be the most appropriate course of action regarding her oral anti-diabetic agents?

MRCP2-1267

A 28-year-old female patient visits the ENT clinic complaining of hoarseness that has persisted for three weeks despite adequate fluid intake. The patient was referred to the clinic by her general practitioner after a phone consultation. Upon examination, a non-painful goiter was observed. The patient denies any symptoms of thyroid dysfunction and reports feeling generally well. She has no difficulty speaking except for the hoarseness and does not experience any breathing difficulties. What is the best course of action to take in this case?

MRCP2-1268

A 50-year-old truck driver presented to the endocrine clinic with complaints of decreased libido and low energy levels. He had a history of head injury 3 years ago, which required 24-hour observation in the hospital. On physical examination, his BMI was 40 kg/m2 and his general and systemic examination was unremarkable.

The following investigations were conducted:

– FT4: 8.1 pmol/l (11.5-22.7)
– TSH: 0.4 mU/l (0.35-5.5)
– FSH: 2.2 U/l (1.4-18.1)
– LH: 3.5 U/l (3.0-8.0)
– Testosterone: 6.8 nmol/l (8.4-28.7)
– IGF-1: 35 nmol/l (16-118)
– Prolactin: 880 mU/l (45-375)

Based on his clinical profile, what is the most likely diagnosis?

MRCP2-1269

A 32-year-old woman contacts the endocrinology nurse seeking advice. She has been experiencing vomiting for the past 24 hours and has been unable to take her regular medications due to this. She has a medical history of Addison’s disease and usually takes oral hydrocortisone and fludrocortisone. She denies any other symptoms apart from reduced oral intake and has not experienced dizziness on standing, blackouts, or diarrhea. Her temperature has been normal. She has IM hydrocortisone available at home. What is the most appropriate advice to give regarding her hydrocortisone?